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Caregiver Screening Tools 1. Modified Caregiver Strain Index1, 2 (To be completed by the caregiver) Directions: Here is a list of things that other caregivers have found to be difficult. Please put a checkmark in the columns that apply to you. We have included some examples that are common caregiver experiences to help you think about each item. Your situation may be slightly different, but the item could still apply. Yes, On a

Regular Basis=2 Yes, Sometimes=1

No=0

My sleep is disturbed (For example: the person I care for is in and out of bed or wanders around at night)

Caregiving is inconvenient (For example: helping takes so much time, or it is a long drive over to help)

Caregiving is a physical strain (For example: lifting in or out of a chair; effort or concentration is required)

Caregiving is confining (For example: helping restricts free time or I cannot go visiting)

There have been family adjustments (For example: helping has disrupted my routine; there is no privacy)

There have been changes in personal plans (For example: I had to turn down a job: I could not go on vacation)

There have been other demands on my time (For example: Other family members need me)

There have been emotional adjustments (For example: Severe arguments about caregiving)

Some behaviour is upsetting (For example: incontinence; the person cared for has trouble remembering things, or the person I care for accuses people of taking things.)

It is upsetting to find the person I care for has changed so much from his/her former self. (For example: he/she is a different person than he/she used to be)

There have been work adjustments (For example: I have to take time off for caregiving duties)

Caregiving is a financial strain I feel completely overwhelmed (For example: I worry about the person I care for; I have concerns about how I will manage)

Sum responses for “Yes, on a regular basis” (2 points each) and “Yes, sometimes” (1 point each) Total Score =

1 Thornton, M, & Travis, S.S. (2003). Analysis of the reliability of the Modified Caregiver Strain Index. The Journal of Gerontology, Series B, Psychological Sciences and Social Sciences, 58(2), S129. 2 The Hartford Institute for Geriatric Nursing (2007). Try This: Best Practices in Nursing Care in Older Adults: The Modified Caregiver Strain Index. Issue #14, available online at: http://www.hartfordign.org/publications/trythis/issue14.pdf Please note this adaptation is for clinical practice purposes only.

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2. Caregiver Risk Factors Screen (to be completed by (referring) Health Provider) Directions: Please consider each caregiver risk factor that may be present.

Self-identifies as stressed Exhibits signs of stress/strain Long-term care-giving role3

Loss or decline in social supports (isolated) Behavioural responses of care recipient present Emotional lability of care recipient present Increasing functional dependence of care recipient on caregiver Historically poor relationship between caregiver and care recipient Poor self-efficacy (“I can do”) beliefs as caregiver Lack of knowledge4 (Example: knowledge of caregiving role, self-care, dementia, etc.) Health issues for caregiver (Example: frailty or poor physical or mental health) Other: (Describe:_____________________________________________________)

Total # of known caregiver risk factors: ______________ Provider Notes Relevant to Referral: ____________________________________________________________________________

____________________________________________________________________________

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Summary: Modified Caregiver Strain Index Score _____________ Risk Factor Score _____________ Decision-making Criterion: Yes No

1. Modified Caregiver Strain Index > 12 and Risk Factor Score >4 or

2. Modified Caregiver Strain Index > 16, regardless of Risk Factor Score or

3. Risk Factor Score > 8, regardless of Modified Caregiver Strain Index Outcomes: Admit to Program (specify:_____________________) Follow-up/Referral(s) to: Notes: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________

3 In a significant care-giving role for greater than one year 4 Evidence that caregiver has not sought knowledge of dementia, caregiving, or self-care information or that caregiver demonstrates or identifies a deficit of knowledge about the caregiving that is required.